New Patient Intake Forms

Following is the information that is critical to your care at True Life Medicine. Please complete and submit within one week of your enrollment:

New Patient

If you are human, leave this field blank.

Contact Info

Full Name
*

Email Address
*

Facebook name - if you are willing to connect there!

Appointment Date
*

By checking this box, I understand that my monthly or annual payments to True Life Medicine are not for services that insurance covers, but for preventative care and non-covered benefits.
*

I agree

Insurance Provider

Insurance Provider number

Your patient information is 100% private. If there are any family members or otherwise who you would like to grant access to, or give us permission to communicate with regarding your care, please list them here:

Patient Profile

Why are you here?

What are the specific, bullet point issues you are primarily at True Life Medicine to address?

What is the cause?

Of course you may be here because you don’t know what led up to your issues. Understood. But if you have some ideas of past events, circumstances, actions or anything that may have added to the ingredients of your issue, please tell us here.

How can we best serve you?

While that may seem like a big, broad question, it’s very serious. Just as your health is very personal and unique and we can not address your issues with a cookie cutter approach, we want to know how you desire to be cared for. Your context may come from experiences you have had with other medical providers

What should we know about you?

To get to the root causes of your wellness, necessitates an in depth understanding of…you. This is a place to be fully know.

What is your overall goal for yourself?

Dr. James likes to reference to ends of the spectrum. Are you hoping to be in the upcoming Olympics? Or are you trying to slide into a nursing home? It’s probably somewhere between those two. Where? What level of health, wellness, ability and vitality are you aiming for?

Personal Info (not required, but helpful for context!)

Are you married? How long?

Do you have children? How many and ages?

Are you employed? What is your vocation or business?

Sleep

How many hours of sleep do you average per night?

Do you toss and turn?

Yes

No

Do you rely on an alarm to wake up in the mornings?

Yes

No

Do you generally feel rested after you wake?

Yes

No

Do you sleep with your mouth open to breathe?

Yes

No

How would you rate the quality of your sleep? On a scale from 1-10, with 10 being the best?

Do you remember dreams?

Yes

No

Nutrition

How often do you eat fruits and vegetable? Do you sometimes go a day without any? Once, twice or three times per day? More? What varieties?

How often do you eat grains?

How often do you eat meat?

How much water do you drink per day?

How much coffee, tea or alcohol per day?

How often do you eat out per week, and how much of that is fast food?

How ofter per week do you eat processed (boxed or preprepared) food?

How often per week do you make and eat home cooked meals?

Do you feel you undereat or overeat?

How well do you feel you digest foods?

Do you take consistent vitamins or supplements? (please list)

Are you currently taking any prescription medications?

Movement

How often per week do you spend with your heart rate elevated?

What physical activities do you engage in daily/weekly?

Do you have any physical limitations?

Work

How would you rate your work environment in regards to your peace, joy and fulfillment? Harmful, neutral, or inspiring?

Do you have a desk job or manual labor job?

Desk Job

Manual Labor Job

Do you feel challenged intellectually?

Yes

No

Do you believe in the product or service you help produce?

Yes

No

Do you feel respected and valued in your role?

Yes

No

How would you rate your stress level at work? Low, Medium, High?

Low

Medium

High

Relationships

If you are married, how would you rate your emotional well being in regards to the relationship? Bad, Average, Good, Great

Bad

Average

Good

Great

Do you feel generally supported and encouraged by your spouse, friends and family? Or discouraged?

Encouraged

Discouraged

Would you say your overall personal relationships are filled with positive or negative interactions?

Positive

Negative

Do you have less than a few close relationship? More than that? Many?

Where do you fall in the spectrum of feeling alone, or having an overabundance of social engagement?